I was in second-year medicine at the Jewish General for our introduction to medicine course, where we learned medical reasoning and how to do a history and physical examination. Our class was the first with a lot of women in the class. We felt like anomalies. We were sat in the intern’s lounge in our new white jackets, their pockets bulging with our newly bought equipment. We were a little insecure about being there. I had a new Chinese cookbook and was showing my friend Janet a promising recipe. One of the senior residents started razzing us.
“I can’t believe you guys read cookbooks!” he sneered. “Can you imagine a bigger waste of time for a doctor? You know you’ll never be smart if you waste your time with that shit.”
Being smart means different things to different people in different milieus. I know for my father, who was forced to leave school and go to work, one’s intelligence was established by the acquisition of a university degree.“What’s a degree” he would say, “but a little piece of paper that says you’re smart?” My father was a self-taught man filled with eclectic knowledge. He had read the entire Encyclopedia Britannica, 1964 edition, using the “Coleridge method.”He could speak learnedly on such subjects as ancient Greek warfare and the life cycle of the butterfly. He introduced me to Rats, Mice and History, a book about the influence of cholera and other epidemic diseases on the history of Europe, arousing my first inklings of interest in medicine.
Yet as brilliant as his mind was, he was still moved to tears when he got his history degree from Concordia at age 60. On that evening of triumph, after he walked proudly across the stage, capped and gowned, to receive his degree, my sister Sandy gave him a wonderful gift. It was a card and inside it was a teeny, tiny bit of paper. On it, in teeny-tiny letters, was written: “You are smart.”
At McGill in the late ’70s, smart people were not supposed to become ‘just GPs.’
Being smart has always been important to me as well. I believe that is why I wandered around in, what for me was, the wastelands of obstetrics and pathology when it was evident to anybody that I should do family medicine. At McGill in the late ’70s, smart people were not supposed to become “just GPs.”
In certain parts of the medical community, the making of complex and obscure diagnoses, particularly of rare diseases, establishes one’s intelligence. I have made a few of these “brilliant” diagnoses, and I pull out the stories from time to time to impress the wide-eyed students. Also, I like to show off.
My first “brilliant diagnosis” as a staff person I attribute solely to my habit of reading cookbooks. I had just joined the staff of the old Queen Elizabeth Hospital in Montreal and was working every week in the emergency room. One Sunday morning, a man was dragged into the ER by his wife. He looked extremely ill. He had been having fevers, daily, for over three months and had lost 30 pounds. He had seen a physician early on who had diagnosed bronchitis and given him Amoxicillin, which hadn’t helped. The patient was one of those men who hated hospitals and doctors, and believed that denial and neglect are the best cure for whatever ails you. His wife wanted him seen.
Usually, diagnosis is 80% in the history, with the rest being mostly in the lab tests. Seldom does the physical examination do much more than confirm what you expect to find after sorting through the story. In this case, however, the story seemed to tell us nothing. The patient could give no clues about how this fever had started or where to find the causal infection. In his case, the physical examination was impressive and disturbing. Every lymph node in his body was bulging and hard. He had lumps the size of eggs in his neck, armpits and groins. The nodes inside his chest were also grossly enlarged on the chest x-ray. When I put my hand on his belly, an enlarged liver and spleen filled the cavity. “Is this lymphoma?” I thought. A few years later, I would have asked about AIDS, but in 1984 AIDS was just beginning to be recognized and was still largely confined to gay men in San Francisco. I was puzzled. He was undoubtedly very sick. We admitted him to the medicine service with my name as the GP. We planned a node and a bone marrow biopsy, which, we were sure, would give us our answer.
I went home that night and started to read about “Fever of Unknown Origin.” A fever that lasts more than six weeks without a diagnosable focus is a classic problem in medicine. There was a whole chapter on it in both Harrison’s and Harvey’s, the two medicine “bibles.” They contained lists of the possible diagnoses. I looked at the strange names and tried to remember something about them. A few days later, the patient was still sick. He was being treated with, what was then, the fashionable antibiotic shotgun cocktail, yet he continued spiking fevers to 39 degrees daily. He could not eat and was wasting visibly. The cultures we took of his every fluid and secretion grew nothing. To our surprise, the lymph node and bone marrow biopsies showed only nonspecific inflammatory changes. We were stumped. It was not cancer. It was not TB or any AIDS-defining illness. What could it be? I thought that somehow the patient would tell us the answer; that he knew the key to the mystery and that we just hadn’t figured out what question to ask. It was kind of like Jeopardy, but with mortal stakes.
I thought that somehow the patient would tell us the answer; that he knew the key to the mystery and that we just hadn’t figured out what question to ask.
I was cooking dinner that night and reading my copy ofJoy of Cooking, searching for a new chicken recipe and reading the chatty bits. I love that cookbook. I love that you can find a recipe for everything in it—from how to make a soft-boiled egg to how to prepare whale meat for a large crowd.
Thoughts of my patient and his mysterious fever intruded on my consciousness. Since we had not yet found or cured our mystery disease, it had to be one of the bizarre infections or inflammations. After dinner, I looked in Harrison’s again. I read about the occupational diseases like Farmer’s Lung or Parrot Keepers Disease.
I came into his hospital room early the next morning before the clinic. His wife was already there and he looked tired and apathetic. I remember sitting in the armchair next to the bed and explaining that I was now pretty sure that an unusual infection was causing the fever. Perhaps it was something that the patient had come into contact with at work or at home just prior to falling ill. I was thinking about parasitic diseases or zoonoses. I questioned them carefully about what he did. He was a renovator of old theatres. He did not recall coming into contact with bird or bat droppings. He hadn’t travelled or drunk well water. But I could see that the patient and his wife were beginning to understand my way of reasoning. The apathy had disappeared. The patient was actively searching his memory for that much-needed key.
Finally, I asked about food. Was he a hunter? Had he been in the woods or in contact with wild game?
His wife sat up straight; I could hear the excitement in her voice. “Those rabbits!” she said. “Those rabbits my brother sent us. They were wild rabbits.”
“Yes,” her husband replied, “They were wild rabbits. But everybody ate those, and nobody else is sick.”
“Everybody ate them,” she explained to me, “but they were cooked. Maybe he accidentally got some of the blood in his mouth?”
All of a sudden, a page in Joy of Cooking came back to me. I saw a line drawing of someone skinning a squirrel, wearing gloves and boots. I remembered having read that section about a spirochetal disease that you could get from small animals such as squirrels, opossums and rabbits. I could not for the life of me, remember the name of the disease. Was it leptospirosis? No. I ran home knowing that I would be late for the clinic and looked it up in my copy of Joy.
Sure enough, there was the drawing just as I had remembered it, and the name of the disease was tularemia. It had been on my list of unusual infections causing fever of unknown origins. I looked it up in Harrison’s. At first, I was disappointed since it did not sound at all like my patient’s symptoms. Turning the page, however, they mentioned more unusual presentations, and there was a complete description of my patient with every one of his signs and symptoms. He had the typhoid-like presentation of tularemia, caused by ingesting the uncooked blood of the infected animal. This disease would not respond to any of the antibiotics we were using but was susceptible to tetracycline. I was sure this was it. I called up the infectious disease specialist who was in charge of the case.
“It might be,” he said, “but that would be very unusual.”
“We’re looking for unusual, aren’t we?” I said.
That night the patient was started on tetracycline. The next day he had no fever. In three days, he was feeling remarkably better. His appetite had returned, and his liver and spleen were shrinking. In two weeks, we had the results. The patient’s blood had indeed been positive for tularemia. Everyone in the hospital was talking about it. The internists looked at me with new respect. I just loved the feeling that all my peers thought that I had made a brilliant diagnosis. People would sit around me in the nursing stations and lounges, asking me diagnostic questions as if I really knew. It fulfilled a weird deep need in me to have my intelligence recognized. I felt, in a way, that I had arrived as a staff doctor. My breadth of knowledge, my way of putting things together from different parts of my life, was my gift.
As for that senior resident, so long ago, who thought that reading cookbooks was a waste of time. Well, he was wrong.